I will admit I'm biased: my mother died of an overdose. She was a drug addict. I, on the other hand, have a painful autoimmune disorder, but I've never taken medication. Yet every doctor I've met in the past ten years has looked at me and immediately treated me like a drug addict. Personal experience aside (as it really is not quantitatively demonstrative of anything larger) I've done my best to research this issue, and I'm still somewhat at a loss. Based on these numbers and the 2016 CDC list of leading causes of death, opiate-related deaths account for .02% of the population. On the other hand, I would guess we have quintuple that in people who suffer chronic pain. Though, I can't say how many use their medication as prescribed, I would guess it's at least more than .02% of the population. Addiction is not simple, and even people who started responsibly taking medication could develop an addiction. I don't think it's fair, however, to punish the many people who depend on pain relief. Lax laws in the 80s and 90s have now pendulum-swung to the other side. Patients are seeing their medication reduced without tapering, they are given no other option than to "suck it up," and all along, they are variously demonized or treated as though they are weak. It's a complicated situation that I am not equipped to solve. I do think there needs to be a middle ground. There needs to be a better effort that will help the entire patient population.

People think that opioids are an effective treatment for long term pain. They aren't. They don't work to treat the pain and the patient develops a tolerance and so ends up taking large quantities putting their health at risk.

> Patients are seeing their medication reduced without tapering, they are given no other option than to "suck it up,"

These are both bad, but these are both symptoms of the sometimes terrible healthcare in the US. People should have access to pain management clinics.

> They don't work to treat the pain and the patient develops a tolerance and so ends up taking large quantities putting their health at risk.

That's not how opioid tolerance works. As dose needed to achieve desired effect (analgesia) increases, so does does needed to cause respiratory depression. It's not like there's a single fixed lethal dose and the hapless addict is drawn into it closer and closer.

Anyway the overwhelming majority of opioid-related deaths, at least in US, occur with concomitant use of benzodiazepines or EtOH (which is something inherently dangerous) and that is, if anything, an argument against prohibition, since people potentiating their opioids with EtOH or benzos is pretty flagrantly downstream of scarcity of opioids.

Long-term use of pharmaceutical-grade opioids (in precisely measured doses, and without the scarcity that drives people to compound with alcohol or benzos) is far safer than you imply it is. It's prohibition that's made opioid use perilous, not the actual pharmacological qualities of the drugs (which have been used by humanity for millennia by now).

> People think that opioids are an effective treatment for long term pain. They aren't

I don't think it's helpful to make a blanket statement like that. There is no one size fits all where pain and analgesics are concerned, and genetics play a large role in what works and what you can even tolerate due to side effects. Opioids of course should not be the first choice, but they should be an option.

I've been living with chronic pain for years now, and have been maintaining the same opioid dose - they bring their own issues, but they make a huge difference to my quality of life. Anecdotally, through support groups, I know several others in the same situation.

There is something of mini war on opioids going on here in the UK, spurred by what's happening in the US and stoked by hate rags like the Daily Mail. People who successfully manage long-term pain using opioids should not be shamed and treated like drug addicts.

I'm pretty sure this is generally accepted to be true in the medical/scientific community (and I suspect isn't new, considering how long opium and its derivatives have been in use). Using "opioid long term pain" or "opioid chronic pain" as search terms for Google or Google Scholar should bring up plenty of reviews and meta-studies that elaborate on this concept.

> 1. Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain.

> 2. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation)

> 3. The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit.

> 4. If a patient is using opioids but is still in pain, the opioids are not effective and should be discontinued, even if no other treatment is available.

> 5. Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detail assessment of the many emotional influences on their pain is essential.

> The experience of pain is complex and influenced by the degree of tissue injury, current mood, previous experience of pain and understanding of the cause and significance of pain. Previous unpleasant thoughts, emotions and experiences can also contribute to the current perception of pain and, if unresolved, can act as a barrier to treatment. The assessment of chronic pain needs to be wide-ranging and comprehensive. The persistence of symptoms is particularly relevant in relation to prescribing where patients may be exposed to cumulative harms of drugs over prolonged periods. If a patient continues to have pain despite taking a number of medications, drugs should be sequentially tapered or stopped to establish continued utility. Similarly, if a patient reports reasonable pain relief from a medication regimen in the longer term, it is also necessary to taper medications intermittently to assess whether the symptoms have resolved spontaneously or whether the patient is relatively pain free because of continued efficacy of medication.

> Medicines are generally less effective for persistent pain than for other types of pain. When medicines are prescribed they should be used in combination with other treatment approaches to support improved physical, psychological and social functioning.

Well, that's a far more nuanced argument than yours. Frankly, you'd be better off quoting that than making veridical statements such as 'does not' when your own evidence indicates it 'sometimes' does. Certainly opioids are not a front line treatment, and never were, but I would avoid going around saying they 'do not work' when clearly sometimes they do and it's a highly contextual decision. You may want to say instead that there is little evidence supporting their widespread use in long term pain management as a primary strategy. That would be supported by what you've posted and I'd take no issue with that statement.

This statement is potentially misleading, since it leaves out the "per year" part. To compare it to the number of chronic pain sufferers, as you've done, you'd need to add up all the deaths of people who would otherwise still be alive.

Even just using the wild approximation of adding up the deaths in Table 27 of what you've linked (interpolating the missing 8 years with the lowest number), brings the percentage above 0.17% or almost 1 in 500.

One of the reasons for alarm is that the fatality rate has been increasing (and may even be accelerating), having more than tripled since 1999. Compare that to vehicle deaths, which have been on a downard trend, even per population.

Now this article is about something different - teaching doctors the warning signs of when already addicted patients are drug seeking, so they can avoid prescribing then. The key fact here is that almost all of the deceased had gotten prescriptions from multiple doctors.

So acute opioid doses 3x your risk of addiction, no matter the strength. And long term dosing will 18x to 150x your risk, depending on the strength. Relatively few people are receiving chronic (90+ days) opioid doses, but those that are have a significant risk of addiction.

I'm not the right person to do this analysis properly, but I'd hardly call this "thoroughly debunked"

Regardless of whether or not this accounts for the majority of addictions, it is sufficient to say that opioids are far more dangerous for patients than many doctors believe. Addressing prescribing habits is a necessary part of a multi-pronged solution to opioid addiction.

"Far greater risk comes from simply being young and from using alcohol and other recreational drugs heavily. Ninety percent of all drug addictions start in the teens — and 75 percent of prescription opioid misuse begins when (mainly young) people get pills from friends, family or dealers — not doctors. Opioids are rarely the first drug people misuse."

All that tells is that there is a layer a indirection. The friends, family, and dealers to some degree get pills from people that got them from doctors. Some may come from overseas, theft, etc., but if 25% are hooked directly from having been prescribed them, I would guess a big portion of the 75% is people within a few hops away.

Often what happens is that the 25% that got hooked from being prescribed start buying additional pills. Eventually they can't afford that and they switch to cheaper heroin, often funded by selling their prescription pills.

You could still draw a link: high prescription rates of opioid pain killers normalises the use of them and as such someone is more likely to be offered them by family and friends for something minor.

Also, is “throughly” debunked really the case? That makes it sound like there can be no link at all, but higher levels of these in society legally could lead to an increase in abuse. On complex topics like this it is rarely possible to talk in absolutes.

What's debunked is the very common narrative in this thread that poor Uncle Billy went to the doctor with a bad back and came back a rabid addict. Non addicts becoming addicts from regular prescriptions is very rare according to all studies.

Imagine having a solution that works for you. It manages your pain. You aren't abusing your medication. Your doctor gets this letter and all of a sudden that option is taken away. Now, that drug hasn't been shown to be unacceptable when taken correctly; and you have been. Now you're in pain again and the solution that had been working for you isn't available for some nebulous reason that isn't directly related to the benefit/risk trade-off you and your doctor already agreed to.

So, your doctor takes you through trying some other drugs, again, just as they had before they prescribed you opioids - as is current best practice. Of course, now, for your doctor that option of opioid use is no longer available, even though it is still there - out of reach. How would that feel? Living without pain management because your doctor fears losing their licence or a letter from the coroner more than helping you manage your pain.

These studies need to ensure doctors are reserving opioids for worst case management, but still prescribing them when nothing less works.

These studies need to be longitudinal. Do patients maintain their quality of life? Are doctors trying less addictive/abusable drugs first?

Focusing on reduced opioid prescription is like focusing on reducing antibiotic use. You have to track infection rates to gauge if the ineffective usage has gone down while maintaining outcomes.

You can't just track usage to gauge the effectiveness of a program. It's a vanity statistic unless you measure outcomes. Outcomes are the whole point.

> “Physiological dependence is the normal response to regular dosages of many medications, whether opioids or others. It also happens with beta blockers for high blood pressure,” said Dr. Wilson Compton, deputy director of the National Institute on Drug Abuse.

Your link says that opioids create physical addiction. The physical addiction to opioids causes all the factors of the newer definition of adddictive: tolerance, drug seeking, preoccupation, and continuing to take it even though you know it's harmful.

Physiological dependence is a treatment complication to be managed. Corticosteroids, hormones, and other nonpsychoactive medications feature this issue too. It is part of the risk/benefit calculation.

What's important is the psychological addiction. You can taper off of a medication on which you are physiologically dependent. However, if it makes you psychologically dependent, you can never forget the high.

Turns out not having pain because a medication helps and you experience it when you stop makes people want to keep taking it. Who knew?

It's when people take more than they need to to address their physical pain, that they experience psychological addiction, that they chase the high, that a problem develops.

Turns out not having pain because a medication helps and you experience it when you stop makes people want to keep taking it. Who knew?

That is not what's happening. People take the medication to treat the pain. Their pain still exists. They develop a tolerance to opioids (one of the mechanisms of addiction) and need to increase the dose. Now they're taking very large -dangerously large- doses of opioids but are still in pain.

Repeat after me. Addiction is not dependence. Dependence is not addiction. When I read "dependence is expected", I will not interpret it as "addiction is expected", and I will ESPECIALLY not immediately assume tolerance, drug seeking, preoccupation, or harming oneself just because of dependence.

I felt exactly the same. And then I ended up with chronic, debilitating, unbearable pain in my limbs.

Opioids are the only thing that has helped with the pain at all - to flip your comment around, not taking opioids could have led to my death.

I only ever take my prescribed dose, and I've been doing this for years. They still have the same efficacy. They don't make me feel good, they constipate me and make me a bit sleepy - I don't know how anyone becomes addicted to them, but amongst many others I guess there are genetic factors at play.

I'm hoping the doctors just got better at finding out which patients were going to multiple doctors for opiates at the same time, since that was the case for almost all of the deceased. The average decrease was only 10% less new subscriptiona. But I wish they studied that also.

I think this could be partially solved by changing the pharmacy systems and moving them to robust electronic systems.

In the US, when I'd get an electronic prescription, I'd have to specify which branch of which pharmacy I was picking it up on. They don't allow electronic prescriptions for opiods, however. (I worked at a pharmacy). Other pharmacies, even in the same chain, could not see my prescriptions without the pharmacy transferring it over to the other physical location. If the pharmacist or doctor suspects something, they basically have to keep the patient waiting to investigate - and if they deny, hope they are getting something wrong instead of someone just getting bad luck.

I now live in Norway. The doctor just does the electronic prescription. I can go to any pharmacy in any location to pick it up. Including the things that aren't allowed to be electronic in the US. This makes such things much easier to be noticed - doctors and pharmacists can get access to this information when filling a prescription.

Not GP but I can expand. Over long periods of use the body develops tolerance to opioids and to get the same level of relief the dose must be increased. This seems to go on forever. Last year I had a patient on 10x what would probably be lethal for me (about 200 times a basic starting dose) and they didn't affect him much at all. He had been on the opiate train for about 30 years.

Indeed, clearly we need to develop a better understanding of the causes of chronic pain and how to treat them directly rather than managing symptoms.

My primary concern is maintaining or improving quality of life without impacting the length too negatively. It's difficult to justify saying "sorry, that thing you were taking to make your life bearable makes my colleagues think I'm no better than drug dealer so, uh, you can't have it any more, here's a pamphlet on mindfulness" - if anything it should be buying time for us to find real solutions instead of symptomatic treatment.

And that's all opioids really do for those that take it - buy time. If we're going to reduce opioid use we need to treat it as we're treating antibiotics and make sure we're carefully watching outcomes to make sure we're not dropping opioids but raising suicide rates.

We owe it to patients to solve their problems and not just treat their symptoms when it's clear they won't heal on their own.

Clearly I'm just a layman but I find it so surprising that the medical community isn't 100% aware of the over prescribing of opiods by now. I have to believe they are totally aware of the situation, but don't know what else to do. Or maybe they're totally fine with it /shrug. I'd love to know more about the medical community's reaction and reformation efforts around the issues with opiods and addiction.

Another factor: Many doctors and hospitals are rated according to patient satisfaction, with reimbursement rates from the government partially based on those satisfaction surveys. And in many cases, if patients have any pain whatsoever, they rate the doctors and hospitals poorly, and therefore the doctors and hospitals get a lower reimbursement rate from the federal government. So doctors and hospitals are incentivized to make patients have no pain whatsoever in recovery, in order to have higher reimbursement rates, even if it means addiction in the long run.

There was a very strong campaign to re-educate physicians to not consider pain as only a symptom. It was suggested that there was liability in not treating pain for the sake of getting rid of pain alone, but mostly it didn’t just change prescribing practices out of fear of liability, the focus of attention on pain changed prescribing habits.

In practice, someone who hardly has enough time for the patients they see, may subconsciously think that in spite of the prevalence of national opioid deaths, no one they treat has died or destroyed their lives through addiction, simply because those who do also stop booking appointments.

Even for doctors who express awareness of the problem with opioid prescribing, it's not uncommon to believe that every other doctor is the problem, and not themselves. Either not realizing their prescribing is above average, or realizing but justifying it with the thought that they somehow have a patient population with above average pain needs.

I guess it’s also an cultural issue. If it’s ok to mute any pain, then not giving opioids is maybe not even considered.

My father had 2 bad operations last year. He suffered a lot of pain afterwards, but he refrained from taking strong drugs. I’m not sure if he did the right thing and if I’d do the same. But there’s is definitely middle ground between killing every pain and enduring all of it.

You were reading the bottle wrong. Those pills were either 5mg or 10mg of hydrocodone with 325mg of acetaminophen. 36 of those, while a lot, is really not more than 4-5 days worth. They only last 4-6 hours each. 325mg hydrocodone would have killed you several times over unless you’re, like, a late stage cancer patient or a severe heroin addict.

Additionally, 600mg Ibuprofen is just 3 of the common over-the-counter 200mg pills. The adult dose for OTC Ibuprofen is 1 or 2 of the 200mg pills, so 600mg is only 150%-300% larger. Whi8le that kind of higher dose can become a problem if used continuously for more than a few days (be careful with any medication), it's a fairly standard dose for a handful of days after a dental procedure. It's certainly not "absurd". (I've been prescribed 1200mg Ibuprofen "every 4-6 hours" a couple times)

I think this is mean and unnecessarily so. People have pain and expect doctors to fix it, but the tools we have to treat it are dangerous. Going too far either way will cripple or destroy lives. Getting the balance right isn't a job anybody is envious of.

I found the letter to be crafted very cleverly. "This person died unnecessarily because of your decisions" then while you're feeling guilty and vulnerable "Here's a program to show you how you can atone"

> but what is different now that makes so many more people get hooked on them?

The US VA noticed that pain was not being adequately treated. They created a campaign to make every HCP ask patients about pain. They looked at the science of the time which seemed to be saying that opioids were not addictive if you use them to treat pain. (they're less addictive if used short term for short term pain (post surgery, for example) but more addictive if used long term.) Drug companies put out new formulations that they claimed were less addictive - turns out they were more addictive. US doctors prescribe huge amounts of opioids.

The tragedy is that pain is still left untreated. The VA campaign meant people got opioids (cheap, but not particularly effective for long term pain) but didn't get access to pain management clinics.

> Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014,1 but there has not been an overall change in the amount of pain Americans report.2,3 During this time period, prescription opioid overdose deaths increased similarly.

> > Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014,1 but there has not been an overall change in the amount of pain Americans report

That, there, is the "money" quote. You've been criticized elsewhere in the thread for the assertion that opiates "don't work" for long-term pain, but that strikes me as a very reasonable summary in the face of this kind of evidence.

Sure, there may be exceptions, but they must be quite rare for the above to remain true. (Some of them may not even be true exceptions, if "intermittent" use for long-term pain actually looks the same as repeated use for short-term pain).

You forgot one: The companies that produce these pills figured out that it is a hugely profitable thing to be selling heroine in pill form (which is more or less what we are talking about) and have been heavily marketing their drugs to doctors and patients. As a consequence all of the things you list are happening and it is hugely profitable.

And when I say marketing here think ads on the tv, heavy lobbying with politicians, inviting doctors to exclusive events and pampering them, sponsoring studies on chronic pain, etc.

I believe that this is mainly a US (or actually North America to include Canada) issue, in most of the EU (Germany being an exception) opioids are not so commonly prescribed outside hospitals or as generic painkillers (i.e. for not really serious illnesses) AFAIK.

the phenomenon seems mostly regional (the colour scale on the map makes very little sense, you need to check the single amounts as everywhere (both North America and EU zone is blue but with very different values ) example 2015, "ME minus Methadone":

I have a condition that meant that until my late teens, I was in incredible pain daily. My parents asked about painkillers, but my doctor at the time strongly cautioned against them, citing dependence and eventual ineffectiveness. His decision and my parents bravery to listen, when all signs pointed toward the need for relief, is likely why I am a fully functional adult today. That was an insight he had over two decades ago, which is why I find the opioid crisis so damning toward the prescribers.

Do the people conducting these studies really think that getting doctors to prescribe less opiates to existing patients and having patients resort to the black market where heroin is often cut with fentanyl, carfentanyl, or other much deadly opiates is really a good idea? Somehow reduced prescriptions are equated with positive outcomes without any proof. I guess the thinking must be that if the patient overdoses off of street opiates it's somehow not as big of a deal as if they overdose off prescribed opiates. At least these doctors won't feel so bad about patients they are directly killing by cutting them off their prescriptions. From experience, most doctors don't even care about or can even fathom the consequences of taking someone dependent on opiates (as well as other drugs that must be tapered like benzodiazepines) so them stopping prescriptions without properly tapering patients off is no big deal while the patients literally scramble to save their lives by getting the drugs from the black market. But hey, the numbers look good and sound good to a society that thinks war should be waged on addicts and that they are better off dead than in recovery. That certainly explains our ridiculous regulations as regards to methadone, an extremely effective treatment for opiate addiction, when used to treat addiction (must be taken in liquid form from a clinic each day etc. etc) vs. when taken for pain. It's almost like these laws were written by people who want addicts to die rather than recover. They are. Doctors who stop prescriptions without offering the patient a chance to recover are essentially sentencing the patient to a possible death penalty either because the patient goes to the black market or because they can't and go through withdrawl which can indeed kill both directly and through suicide. They should really try to remember the Hippocratic oath they are violating and think about the patients they are directly trying to kill in the name of prescription reduction and useless, dumb government statistics.